Surgical site infection in severe trauma patients in intensive care: epidemiology and risk factors

BACKGROUND

Severe trauma is the leading cause of disability and mortality in the patients under 35 years of age. Surgical site infections (SSI) represent a significant complication in this patient population. However, they are often inadequately investigated, potentially impacting the quality of patient outcomes. The aim of this study was to investigate the epidemiology of SSI and risk factors in severe trauma patients.

METHODS

We conducted a multicenter retrospective cohort study screening the severe trauma patients (STP) admitted to two intensive care units of an academic institution in Marseille between years2018 and 2019. Those who underwent orthopedic or spinal surgery within 5 days after admission were included and classified into two groups according to the occurrence of SSI (defined by the Centers for Disease Control (CDC) international diagnostic criteria) or not. Our secondary goal was to evaluate STP survival at 48 months, risk factors for SSI and microbiological features of SSI.

RESULTS

Forty-seven (23%) out of 207 STP developed an SSI. Mortality at 48-months did not differ between SSI and non-SSI patients (12.7% vs. 10.0%; p = 0.59). The fractures of 22 (47%) severe trauma patients with SSI were classified as Cauchoix 3 grade and 18 (38%) SSI were associated with the need for external fixators. Thirty (64%) severe trauma patients with SSI had polymicrobial infection, including 34 (72%) due to Gram-positive cocci. Empirical antibiotic therapy was effective in 31 (66%) cases. Multivariate analysis revealed that risk factors such as low hemoglobin, arterial oxygenation levels, hyperlactatemia, high serum creatinine and glycemia, and Cauchoix 3 grade on the day of surgery were associated with SSI in severe trauma patients. The generated predictive model showed a good prognosis performance with an AUC of 0.80 [0.73-0.88] and a high NPV of 95.9 [88.6-98.5] %.

CONCLUSIONS

Our study found a high rate of SSI in severe trauma patients, although SSI was not associated with 48-month mortality. Several modifiable risk factors for SSI may be effectively managed through enhanced perioperative monitoring and the implementation of a patient blood management strategy.

Ghrelin may protect against vascular endothelial injury in Acute traumatic coagulopathy by mediating the RhoA/ROCK/MLC2 pathway

Ghrelin exerts widespread effects in several diseases, but its role and mechanism in Acute Traumatic Coagulopathy (ATC) are largely unknown. The effect of ghrelin on cell proliferation was examined using three assays: 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT), Lactate Dehydrogenase (LDH), and flow cytometry. The barrier function of the endothelial cells was evaluated using the Trans-Endothelial Electrical Resistance (TEER) and the endothelial permeability assay. An ATC mouse model was established to evaluate the in vivo effects of ghrelin. The Ras homolog family member A (RhoA) overexpression plasmid or adenovirus was used to examine the molecular mechanism of ghrelin. Ghrelin enhanced Human Umbilical Vein Endothelial Cells (HUVEC) proliferation and endothelial cell barrier function and inhibited HUVEC permeability damage in vitro. Additionally, ghrelin decreased the activated Partial Thromboplastin Time (aPTT) and Prothrombin Time (PT) in mice blood samples in the ATC mouse model. Ghrelin also improved the pathological alterations in postcava. Mechanistically, ghrelin acts through the RhoA/ Rho-associated Coiled-coil Containing Kinases (ROCK)/ Myosin Light Chain 2 (MLC2) pathway. Furthermore, the protective effects of ghrelin, both in vitro and in vivo, were reversed by RhoA overexpression. Our findings demonstrate that ghrelin may reduce vascular endothelial cell damage and endothelial barrier dysfunction by blocking the RhoA pathway, suggesting that ghrelin may serve as a potential therapeutic target for ATC treatment.

Management of massive haemorrhage in transfusion medicine services in the Middle East and North Africa

BACKGROUND AND OBJECTIVES

Massive transfusion protocols (MTPs) are critical in managing haemorrhage, yet their utilization varies. There is lack of data on the utilization of MTPs in the Middle East and North Africa (MENA) region. This study aims to assess the degree of utilization of MTPs in the region.

MATERIALS AND METHODS

We conducted a survey to collect data on MTP use, inviting medical directors of transfusion services from various hospitals. Data were analysed to determine the prevalence of MTP utilization, their compositions, challenges in application and areas of future need.

RESULTS

Eighteen respondents participated, representing 11 countries in the region. Thirteen hospitals implemented MTP, and eight included paediatrics. Eleven institutions used more than one definition of massive haemorrhage, with the most common being ≥10 red blood cell (RBC) units transfused for adults and replacement of >50% total blood volume in paediatrics. The majority of sites with MTPs utilized 1:1:1 RBCs:platelets:plasma ratio (70%). Variations were observed in the types and blood groups of components used. Two sites utilized whole blood, while six are considering it for future use. Utilization of adjunctive agents and frequency of laboratory testing varied among the sites. Challenges included the lack of medical expertise in protocol development, adherence and paediatric application. The need assessment emphasized the need for developing regional guidelines, standardized protocols and training initiatives.

CONCLUSION

Although several hospitals have adopted MTPs, variations exist in activation criteria, blood product ratios and monitoring. Challenges include the lack of medical expertise, protocol adherence and addressing paediatric needs. Standardizing protocols, enhancing training and paediatric application are crucial for improving massive transfusion management in the region.

Predictors for anaemia, blood transfusion and outcome in plastic surgery patients

OBJECTIVE

In patients undergoing plastic surgery, to identify specific risk factors for anaemia and use of blood products, and assess their impact on patient outcome.

METHOD

For this retrospective study, data were analysed from patients who attended the Plastic Surgery Department at our hospital over a three-year period (2018 to 2020). Adult patients who presented with traumatic injuries, oncologic patients who underwent reconstructive procedures, and patients with soft tissue infections (STIs) who required plastic surgery for tissue coverage were included. Demographic and injury data, hospital admission characteristics, surgical procedures, laboratory test results, transfusion events, and in-hospital complications were extracted from patient records.

RESULTS

Of the 350 patients included in the study, 228 (65%) presented with trauma, 76 (22%) underwent reconstructive surgery for cancers and 46 (13%) had STIs. In total, 175 (50%) patients developed anaemia, and 37 (11%) received blood transfusions; these were 20 (54%), 5 (14%), and 12 (32%) patients in the trauma, cancer and STI groups, respectively. Associated comorbidities and upper and lower limb surgery were the most significant risk factors for anaemia, while the number of surgeries and NSTIs were identified as risk factors for blood transfusions. Direct wound closure was consistently a protective factor for both anaemia and blood transfusions. Blood transfusions were independently associated with a high risk of sepsis, wound complications, and prolonged hospital stay.

CONCLUSION

While transfusions are necessary and even lifesaving in surgical patients, blood is a finite resource and its use may negatively impact patient outcome. Therefore, ongoing research must focus on providing safe and restrictive clinical practices while developing sustainable and accessible alternatives.

Prehospital Blood Transfusion: A Cross-Sectional Study of Prehospital and Retrieval Medicine Services across Australia & Aotearoa-New Zealand

BACKGROUND

The frequency and type of prehospital blood product delivery across Australia and Aotearoa-New Zealand is unknown. This study aims to describe transfusion practice across different services in the two nations, as well as identifying potential barriers to the carriage of blood products.

METHODOLOGY

Prehospital and retrieval medicine services operating teams of doctors, specialist paramedics, and/or flight nurses out of specialty bases across Australia and Aotearoa-New Zealand were sent a standardized questionnaire regarding their base characteristics and their current blood transfusion practice. Bases that only performed inter-hospital transfers or search & rescue operations were excluded. Bases were queried on personnel, equipment, transport times, type and volume of blood products carried, frequency of use, and barriers to implementation for those without prehospital blood transfusion programs.

RESULTS

64 bases were identified and contacted, of which 5 were excluded and 45 of the remaining 59 (76.3%) responded. 62% (28/45) of respondents routinely carry prehospital blood products. 78.6% (22/28) carried packed red blood cells (PRBC) only, 14.3% (4/28) carried both PRBC and plasma, and 1 service (3.6%) carried whole blood. The mean number of units of blood product carried was 3.3 (SD 0.82). 2 bases (7.1%) carried fibrinogen concentrate. All services carried tranexamic acid and calcium. 734 patients received a blood transfusion in 2021, with trauma being the most common indication (552, 75.2%). Base characteristics varied significantly in staffing, vehicle platform and transfer times. The median transfer time from scene to hospital was 65 min (IQR of 40-92). Services without access to prehospital blood products identified multiple barriers to implementation, including training and supply chain.

CONCLUSION

Approximately two-thirds of prehospital services operating advanced teams across Australia and Aotearoa-New Zealand carried blood products and there was wide variation both in the type and number of blood products carried by each base. Multiple barriers to the carriage of blood by all bases were reported, which have implications for service equity. Transfer times are generally long in Australia and Aotearoa-New Zealand, which may impact the generalizability of overseas research performed in prehospital systems with significantly shorter transfer times to services operating in Australia and Aotearoa-New Zealand.

The Application of PiCCO-guided Fluid Resuscitation in Patients With Traumatic Shock

BACKGROUND

The aim of this study was to evaluate the application of pulse contour cardiac output (PiCCO) in patients with traumatic shock.

METHODS

Seventy-eight patients with traumatic shock were included and grouped. The control group (CG, n = 39) underwent fluid resuscitation through transthoracic echocardiography (TTE) monitoring, and the research group (RG, n = 39) received PiCCO-guided fluid resuscitation.

RESULTS

The mechanical ventilation time, duration of vasoactive drug use, and duration of stay in the intensive care unit were lower in the RG compared to the CG (P < .05). At 72 h after fluid resuscitation, the mean arterial pressure and central venous pressure in the RG were higher than those in the CG (P < .05). The stroke volume variation and distensibility index of the inferior vena cava were lower at 72 h after fluid resuscitation, but the levels of extravascular lung water, global end-diastolic volume index, and intrathoracic blood volume index were higher in the RG (P < .05). The levels of endothelial 1, nitrogen monoxide, tumor necrosis factor-α, procalcitonin, C-reactive protein, and partial pressure of carbon dioxide at 72 h after fluid resuscitation in the RG were lower than those in the CG (P < .05).

CONCLUSION

PiCCO-guided liquid resuscitation may help to accurately evaluate the volumetric parameters, alleviate symptoms of ischemia and hypoxia, regulate hemodynamics and blood gas analysis, reduce inflammatory reactions, improve endothelial functions, and effectively guide the usage of vascular active drugs.

Air Medical Blood Transfusion as a Trigger of Massive Transfusion Protocol

Air medical services can improve access to blood products at the point of injury. Studies have shown that early activation of mass transfusion protocols (MTPs) can improve the survival of trauma patients by up to 25%. There are several scoring systems to guide early activation, but the use of a single criterion has been elusive. Our study sought to determine if air medical administration of blood products was a risk factor for massive transfusion activation and utilization of prehospital vital signs for calculation of the shock index. In our retrospective study, we evaluated adult trauma patients transfused by helicopter emergency medical services (HEMS) and as a control all patients in our institution receiving the MTP. Our study found HEMS blood transfusion was not a reliable trigger for MTP, although the sample size may have limited our findings. We found that HEMS care resulted in an overall reduction in the volume of transfusion and an improvement in hemodynamic parameters upon trauma center arrival. HEMS transfusion and a higher rate of tranexamic acid administration may have contributed to these findings. Of note, the assessment of blood consumption score and shock index were nonspecific in the study populations.

A Systematic Review of Tranexamic Acid-Associated Venous Thromboembolic Events in Combat Casualties and Considerations for Prolonged Field Care

INTRODUCTION

Tranexamic acid (TXA) is a standard component of Tactical Combat Casualty Care. Recent retrospective studies have shown that TXA use is associated with a higher rate of venous thromboembolic (VTE) events in combat-injured patients. We aim to determine if selective administration should be considered in the prolonged field care environment.

MATERIALS AND METHODS

We performed a systematic review using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Clinical trials and observational studies of combat casualties published between January 1, 1960, and June 20, 2022, were included. We analyzed survival and VTE outcomes in TXA recipients and non-recipients. We discussed the findings of each paper in the context of current and future combat environments.

RESULTS

Six articles met criteria for inclusion. Only one study was powered to report mortality data, and it demonstrated a 7-fold increase in survival in severely injured TXA recipients. All studies reported an increased risk of VTE in TXA recipients, which exceeded rates in civilian literature. However, five of the six studies used overlapping data from the same registry and were limited by a high rate of missingness in pertinent variables. No VTE-related deaths were identified.

CONCLUSIONS

There may be an increased risk of VTE in combat casualties that receive TXA; however, this risk must be considered in the context of improved survival and an absence of VTE-associated deaths. To optimize combat casualty care during prolonged field care, it will be essential to ensure the timely administration of VTE chemoprophylaxis as soon as the risk of significant hemorrhage permits.

The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results

INTRODUCTION

In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future.

OBJECTIVE

A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results.

METHODS

This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute.

FINDINGS

From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion.

CONCLUSION

Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.

Extracellular RNA Sensing Mediates Inflammation and Organ Injury in a Murine Model of Polytrauma

Severe traumatic injury leads to marked systemic inflammation and multiorgan injury. Endogenous drivers such as extracellular nucleic acid may play a role in mediating innate immune response and the downstream pathogenesis. Here, we explored the role of plasma extracellular RNA (exRNA) and its sensing mechanism in inflammation and organ injury in a murine model of polytrauma. We found that severe polytrauma-bone fracture, muscle crush injury, and bowel ischemia-induced a marked increase in plasma exRNA, systemic inflammation, and multiorgan injury in mice. Plasma RNA profiling with RNA sequencing in mice and humans revealed a dominant presence of miRNAs and marked differential expression of numerous miRNAs after severe trauma. Plasma exRNA isolated from trauma mice induced a dose-dependent cytokine production in macrophages, which was almost abolished in TLR7-deficient cells but unchanged in TLR3-deficient cells. Moreover, RNase or specific miRNA inhibitors against the selected proinflammatory miRNAs (i.e., miR-7a-5p, miR-142, let-7j, miR-802, and miR-146a-5p) abolished or attenuated trauma plasma exRNA-induced cytokine production, respectively. Bioinformatic analyses of a group of miRNAs based on cytokine readouts revealed that high uridine abundance (>40%) is a reliable predictor in miRNA mimic-induced cytokine and complement production. Finally, compared with the wild-type, TLR7-knockout mice had attenuated plasma cytokine storm and reduced lung and hepatic injury after polytrauma. These data suggest that endogenous plasma exRNA of severely injured mice and ex-miRNAs with high uridine abundance prove to be highly proinflammatory. TLR7 sensing of plasma exRNA and ex-miRNAs activates innate immune responses and plays a role in inflammation and organ injury after trauma.

Etiology and management of hypofibrinogenemia in trauma

PURPOSE OF REVIEW

Fibrin polymerization is essential for stable clot formation in trauma, and hypofibrinogenemia reduces hemostasis in trauma. This review considers fibrinogen biology, the changes that fibrinogen undergoes after major trauma, and current evidence for lab testing and treatment.

RECENT FINDINGS

Fibrinogen is a polypeptide that is converted to fibrin by the action of thrombin. During trauma, fibrinogen levels are consumed and reduce within the first few hours because of consumption, dilution, and fibrinolysis. Fibrinogen levels usually rebound within 48 hours of injury and can contribute to thrombotic events. The Clauss fibrinogen assay is the gold standard test for fibrinogen levels, although viscoelastic hemostatic assays are often used when a lab delay is anticipated. An evidence-based threshold for fibrinogen replacement is not well established in the literature, but expert opinion recommends maintaining a level above 150 mg/dl.

SUMMARY

Hypofibrinogenemia is an important cause of nonanatomic bleeding in trauma. Despite multiple pathologic causes, the cornerstone of treatment remains fibrinogen replacement with cryoprecipitate or fibrinogen concentrates.

Blood coagulation test abnormalities in trauma patients detected by sonorheometry: a retrospective cohort study

Background

Traumatic hemorrhage guidelines include point-of-care viscoelastic tests as a standard of care. Quantra (Hemosonics) is a device based on sonic estimation of elasticity via resonance (SEER) sonorheometry to assess whole blood clot formation.

Objectives

Our study aimed to assess the ability of an early SEER evaluation to detect blood coagulation test abnormalities in trauma patients.

Methods

We conducted an observational retrospective cohort study with data collected at hospital admission of consecutive multiple trauma patients from September 2020 to February 2022 at a regional level 1 trauma center. We performed a receiving operator characteristic curve analysis to determine the ability of the SEER device to detect blood coagulation test abnormalities. Four values on the SEER device were analyzed: clot formation time, clot stiffness (CS), platelet contribution to CS, and fibrinogen contribution to CS.

Results

A total of 156 trauma patients were analyzed. The clot formation time value predicted an activated partial thromboplastin time ratio of >1.5 with an area under the curve (AUC) of 0.93 (95% CI, 0.86-0.99). The AUC of the CS value in detecting an international normalized ratio of prothrombin time of >1.5 was 0.87 (95% CI, 0.79-0.95). The AUC of fibrinogen contribution to CS to detect a fibrinogen concentration of <1.5 g/L was 0.87 (95% CI, 0.80-0.94). The AUC of platelet contribution to CS to detect a platelet concentration of <50 G/L was 0.99 (95% CI, 0.99-1.00).

Conclusion

Our results suggest that the SEER device may be useful for the detection of blood coagulation test abnormalities at trauma admission.

Risk Factors of Perioperative Brain Injury in Children Under Two Years Undergoing Coarctation Repair

BACKGROUND

To investigate clinical manifestations and factors of perioperative brain injury (PBI) after surgical repair of coarctation of the aorta (CoA) combined with other heart malformations under cardiopulmonary bypass (CPB) in children under two years.

METHODS

The clinical data of 100 children undergoing CoA repair were retrospectively reviewed between January 2010 and September 2021. Univariate and multivariate analyses were performed to identify factors of PBI development. Hierarchical and K-means cluster analyses were conducted to evaluate the association between hemodynamic instability and PBI.

RESULTS

Eight children developed postoperative complications, and all of them had a favorable neurological outcome one year after surgery. Univariate analysis revealed eight risk factors associated with PBI. Multivariate analysis indicated operation duration (P = 0.04, odds ratio [OR], 2.93; 95% confidence interval [CI], 1.04 to 8.28) and pulse pressure (PP) minimum (P = 0.01; OR, 0.22; 95% CI, 0.06 to 0.76) were independently associated with PBI. The following three parameters emerged for cluster analysis: PP minimum, mean arterial pressure (MAP) dispersion, and systemic vascular resistance (SVR) average. Using cluster analysis, PBI mainly occurred in subgroups 1 (12%, three of 26) and 2 (10%, five of 48). The mean value of PP and MAP in subgroup 1 was significantly higher than in subgroup 2. The mean SVR in subgroup 1 was the highest. The lowest PP minimum, MAP, and SVR were observed in subgroup 2.

CONCLUSION

Lower PP minimum and longer operation duration were independent risk factors for developing PBI in children under two years during CoA repair. Unstable hemodynamics should be avoided during CPB.

circ_0001274 Competitively Binds miR-143-3p to Upregulate VWF Expression to Improve Acute Traumatic Coagulopathy

Accumulating evidence has noted the circRNA-microRNA- (circRNA-miRNA-) mRNA competing endogenous RNA (ceRNA) regulatory network in disease development and progression. The current study explored the ceRNA network in acute traumatic coagulopathy (ATC). Potential ATC-related genes were screened, and upstream miRNAs and circRNAs of VWF (the candidate target) were assayed through database searching and high-throughput sequencing technology. circ_0001274/miR-143-3p/VWF ceRNA regulatory network was constructed and validated. The expression of circ_0001274/miR-143-3p/VWF was determined in the peripheral blood samples from ATC patients and ATC mouse models. Online database and circRNA sequencing analysis results identified VWF as a key gene in ATC as supported by assays and that VWF was lowly expressed in ATC patients and mice. Further experiments demonstrated that miR-143-3p could target and inhibit VWF, and circ_0001274 could competitively sponge miR-143-3p. Functionally, circ_0001274 could competitively sequester miR-143-3p to upregulate VWF expression, potentially improving ATC. Our study highlights the critical role of circ_0001274/miR-143-3p/VWF axis in improving ATC.

Raising the bar on fibrinogen: a retrospective assessment of critical hypofibrinogenemia in severely injured trauma patients

Objectives

Fibrinogen depletion may occur at higher levels than historically referenced. We evaluated hypofibrinogenemia and associated mortality and multiple organ failure (MOF) after severe injury.

Methods

Retrospective investigation including 417 adult patients with Injury Severity Score (ISS) >15. Demographics and injury characteristics were collected. Fibrinogen within 30 minutes of admission was described: <150 mg/dL, 150 mg/dL to 200 mg/dL and >200 mg/dL. Primary outcome: 28-day mortality. Secondary outcomes: 28-day MOF and blood product transfusion. Multivariable logistic regression model evaluated association of fibrinogen categories on risk of death, after controlling for confounding variables. Results presented as OR and 95% CIs.

Results

Fibrinogen <150 mg/dL: 4.8%, 150 mg/dL to 200 mg/dL: 18.2%, >200 mg/dL: 77.0%. 28-day mortality: 15.6%. Patients with <150 mg/dL fibrinogen had over fourfold increased 28-day mortality risk (OR: 4.9, 95% CI 1.53 to 15.7) after adjusting for age, ISS and admission Glasgow Coma Scale. Patients with lower fibrinogen were more likely to develop MOF (p=0.04) and receive larger red blood cell transfusion volumes at 3 hours and 24 hours (p<0.01).

Conclusions

Fibrinogen <150 mg/dL is significantly associated with increased 28-day mortality. Patients with fibrinogen <150 mg/dL were more likely to develop MOF and required increased administration of blood products. The optimal threshold for critically low fibrinogen, the association with MOF and subsequent fibrinogen replacement requires further investigation.

Level of evidence

Level III.

SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock

Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.

National analysis of whole blood and component versus component transfusions in civilian trauma patients who underwent a thoracotomy or laparotomy: Toward improving patient outcomes and quality of care

BACKGROUND

This study aimed to investigate the associations of whole blood and component versus component transfusions with in-hospital mortality, complication rates, intensive care unit length of stay, and packed red blood cells transfusion volumes in adult civilian trauma patients.

METHODS

We performed a retrospective cohort study of the American College of Surgeons Trauma Quality Program Participant Use File 2016 to 2019 dataset. Adult civilian trauma patients (aged >18 years) sustaining injuries of at least moderate severity who received whole blood and component or component within 4 hours of arrival and underwent thoracotomy or laparotomy were included. Multivariable regression analysis was used to compare outcomes between whole blood and component and component groups.

RESULTS

A total of 37,384 patients met eligibility criteria, of which 218 received whole blood and component and 37,166 received component. There was no significant difference in in-hospital mortality between whole blood and component and component groups for those who underwent thoracotomy (adjusted odds ratio = 0.408, P = .413) or laparotomy (adjusted odds ratio = 1.046, P = .857). Thoracotomy patients who received whole blood and component had no difference in 4-hour or 24-hour pack red blood cell volumes (3336 mL vs 3106 mL, P = .754; 3 658mL vs 3,636mL, P = .982), intensive care unit length of stay (10.68 days vs 8.63 days, P = .542), or complications rates compared to those who received component. Laparotomy patients who received whole blood and component had no difference in 4 hour or 24-hour packed red blood cell volumes (2,758 mL vs 2,721mL, P = .927; 3,538 mL vs 3,385 mL, P = .754), intensive care unit length of stay (11.78 days vs 9.90 days, P = .177), or complications rates compared to those who received component.

CONCLUSION

Study findings have indicated that a combined resuscitation with whole blood and component transfusion in adult civilian trauma patients is a viable alternative to component transfusion alone.

An Emerging Strategy for Muscle Evanescent Trauma Discrimination by Spectroscopy and Chemometrics

Trauma is one of the most common conditions in the biomedical field. It is important to identify it quickly and accurately. However, when evanescent trauma occurs, it presents a great challenge to professionals. There are few reports on the establishment of a rapid and accurate trauma identification and prediction model. In this study, Fourier transform infrared spectroscopy (FTIR) and microscopic spectroscopy (micro-IR) combined with chemometrics were used to establish prediction models for the rapid identification of muscle trauma in humans and rats. The results of the average spectrum, principal component analysis (PCA) and loading maps showed that the differences between the rat muscle trauma group and the rat control group were mainly related to biological macromolecules, such as proteins, nucleic acids and carbohydrates. The differences between the human muscle trauma group and the human control group were mainly related to proteins, polysaccharides, phospholipids and phosphates. Then, a partial least squares discriminant analysis (PLS-DA) was used to evaluate the classification ability of the training and test datasets. The classification accuracies were 99.10% and 93.69%, respectively. Moreover, a trauma classification and recognition model of human muscle tissue was constructed, and a good classification effect was obtained. The classification accuracies were 99.52% and 91.95%. In conclusion, spectroscopy and stoichiometry have the advantages of being rapid, accurate and objective and of having high resolution and a strong recognition ability, and they are emerging strategies for the identification of evanescent trauma. In addition, the combination of spectroscopy and stoichiometry has great potential in the application of medicine and criminal law under practical conditions.

Platelet-Inspired Intravenous Nanomedicine for Injury-Targeted Direct Delivery of Thrombin to Augment Hemostasis in Coagulopathies

Severe hemorrhage associated with trauma, surgery, and congenital or drug-induced coagulopathies can be life-threatening and requires rapid hemostatic management via topical, intracavitary, or intravenous routes. For injuries that are not easily accessible externally, intravenous hemostatic approaches are needed. The clinical gold standard for this is transfusion of blood products, but due to donor dependence, specialized storage requirements, high risk of contamination, and short shelf life, blood product use faces significant challenges. Consequently, recent research efforts are being focused on designing biosynthetic intravenous hemostats, using intravenous nanoparticles and polymer systems. Here we report on the design and evaluation of thrombin-loaded injury-site-targeted lipid nanoparticles (t-TLNPs) that can specifically localize at an injury site via platelet-mimetic anchorage to the von Willebrand factor (vWF) and collagen and directly release thrombin via diffusion and phospholipase-triggered particle destabilization, which can locally augment fibrin generation from fibrinogen for hemostatic action. We evaluated t-TLNPs in vitro in human blood and plasma, where hemostatic defects were created by platelet depletion and anticoagulation. Spectrophotometric studies of fibrin generation, rotational thromboelastometry (ROTEM)-based studies of clot viscoelasticity, and BioFlux-based real-time imaging of fibrin generation under simulated vascular flow conditions confirmed that t-TLNPs can restore fibrin in hemostatic dysfunction settings. Finally, the in vivo feasibility of t-TLNPs was tested by prophylactic administration in a tail-clip model and emergency administration in a liver-laceration model in mice with induced hemostatic defects. Treatment with t-TLNPs was able to significantly reduce bleeding in both models. Our studies demonstrate an intravenous nanomedicine approach for injury-site-targeted direct delivery of thrombin to augment hemostasis.

Design for a Multicentre Prospective Cohort for the Assessment of Platelet Function in Patients with Hepatitis-B-Virus-Related Acute-on-Chronic Liver Failure

Background

Acute-on-chronic liver failure (ACLF) has high short-term mortality and lacks sufficient medical therapy. Available algorithms are unable to precisely predict short-term outcomes or safely stratify patients with ACLF as emergent liver transplantation candidates. Therefore, a personalized prognostic tool is urgently needed.

Purpose

Platelet function and its clinical significance in ACLF patients with chronic hepatitis B virus (HBV) infection have not been investigated. This study aimed to assess changes in platelet function using thromboelastography (TEG) and platelet mapping (TEG-PM) in HBV-related ACLF patients.

Methods

Chronic liver disease patients with acute decompensation or acute hepatic injury were recruited. The derivation cohort enrolled HBV-related patients at Nanfang Hospital. HBV-related and non-HBV-related patients were both enrolled in internal and external validation cohorts at seven university hospitals. TEG and TEG-PM were performed at baseline in the derivation cohort and baseline, day 7, and day 14 in the validation cohorts. The primary outcome was all-cause 28-day mortality. Status check and new-onset complications were recorded during the 3-month follow-up, but status check will extend to 5 years.

Conclusion and Future Plans

In this study, 586 participants were enrolled, including 100 in derivation cohort, 133 in internal validation cohort, and 353 in external validation cohort. Biomaterials, including plasma, serum, urine, and some explanted liver tissues, were collected from these patients. A 3-month follow-up with survival status was completed. The baseline characteristics indicated that 51% of the patients had adenosine diphosphate (ADP)-hyporesponsive circulating platelets. The prognostic potential of platelet function will be explored in the derivation cohort (HBV-related ACLF patients) and further substantiated in the validation cohorts (HBV-related and non-HBV-related ACLF patients). Biosamples are currently used to explore the underlying mechanisms related to ADP-hyporesponsive platelets. The ongoing proteomic and metabolic analyses will provide new insights into the pathogenesis of extrahepatic organ failures in ACLF patients.

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings

Background

Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) "Interior Committee" was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina.

Methods

Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an "AATO Exterior Committee" consisting of surgeons that practice in Buenos Aires, and 2 "Interior Committees," comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures.

Results

Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees.

Conclusion

While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.

Adverse transfusion reactions and what we can do

INTRODUCTION

Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions.

AREAS COVERED

According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions.

EXPERT OPINION

The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Do the benefits of prophylactic inferior vena cava filters outweigh the risks in trauma patients? A meta-analysis

INTRODUCTION

The aim of this systematic review and meta-analysis was to evaluate whether the benefits of prophylactic inferior vena cava filters (IVCF) outweigh the risks thereof.

PATIENTS AND METHODS

PubMed, EMBASE, and Cochrane Library were systematically searched for records published from 1980 to 2018 by two independent researchers (MG, GG). The endpoints of interest were pulmonary embolism (PE) and deep vein thrombosis (DVT) rates. Quality assessment, data extraction and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio and 95% confidence interval (OR (95%CI)) as the measure of effect size was utilized for meta-analysis.

RESULTS

Fifteen studies (two randomized controlled trials and 13 observational studies) were included in the meta-analysis. PE rate was 0.9% (11/1183) in IVCF vs. 0.6% (240/39,417) in No IVCF. This difference was not statistically significant [OR (95%CI) = 0.31 (0.06, 1.51); p = 0.15]. DVT rate was 8.4% (77/915) in IVCF vs. 1.7% (653/38,807) in No IVCF. The difference was not statistically significant [OR (95%CI) = 2.67 (0.90, 7.98); p = 0.08]. In the subset of RCTs, PE rate was 0% (0/64) in IVCF vs. 12% (6/5) in No IVCF. This difference was statistically significant [OR (95%CI) = 0.12 (0.01, 1.03); p = 0.05].

CONCLUSIONS

This meta-analysis found that prophylactic IVCF may be associated with decreased PE rates at the possible cost of increased DVT rates. Further observational and experimental clinical studies are needed to confirm the findings of this meta-analysis.

Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol

INTRODUCTION

Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear.

METHODS AND ANALYSIS

This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock.

PRIMARY OBJECTIVE

the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions.

INCLUSION CRITERIA

age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04760977.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Advancing in the understanding of coagulopathy during hemorrhagic shock: From the triad to the deadly pentad

The deadly triad concept represented a dogma in the definition of poor outcomes and death associated with major bleeding in trauma. This model of end-stage disease was then rapidly transferred to other major bleeding scenarios. However, and notwithstanding the fact that it represented a severe scenario, the original triad fails to establish a sequence, which would be relevant when defining the objectives during the initial treatment of severe bleeding.  It has been recently suggested that hypoxia and hyperglycemia should be included as isolated, determining factors in this model. Likewise, the model admits only one scenario where all the conditions shall co-exist, knowing that each one of them contributes with a different risk burden. Based on a structured review, we submit a pentad model that includes a natural pattern of events occurring with hypoxemia as the main trigger for the development of hypocalcemia, hyperglycemia, acidosis and hypothermia, as hallmarks of multiple system impairment. This severity model of major bleeding ends with coagulopathy as a result of the failure to resolve the rest of the previous components.

“Zooming” in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé?

OBJECTIVE:

Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days.

METHODS:

This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy.

RESULTS:

The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected.

CONCLUSIONS:

Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment.

Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma

INTRODUCTION

Hemorrhage in major trauma is life-threatening and the activation of the Massive Transfusion Protocol (MTP) was found to reduce the time to transfusion and mortality. The purpose was (i) to verify whether MTP activation identifies patients that require massive transfusions once admitted to the Emergency Department (ED), (ii) to establish whether pre-hospital MTP activation reduces the time to transfusion on arrival at the ED, (iii) to identify the variable that best predicts MTP activation.

MATERIALS AND METHODS

This is a retrospective, single-center study. The MTP was implemented at the end of 2012; it was activated for major trauma in pre-hospital setting on the basis on established criteria. Pre-hospital MTP activation aimed to make blood products available prior to the patients' arrival at the ED. The blood products are transfused when the patient arrives at the hospital.

RESULTS

The MTP was activated in pre-hospital setting in 219 patients. On arrival at the hospital, the Trauma Team Leader confirmed MTP activation in 146 (66.7%) patients. Patients with MTP criteria received a higher amount of blood products than the patients without MTP criteria, median 7 (IQR 2-13) units versus 2 (0-6) units, respectively (P < 0.001). At the same time, patients with a Shock Index ≥ 0.9 received more transfusions (5.5 [2-13] units) compared with patients characterized by a lower SI (2 [0-7.25] units, P = 0.009). 146 patients were transfused in the first hour of ED admission. Poisson's multiple regression shows that the SI is the variable that better predicted MTP activation compared to age, gender and the number of injured sites.

CONCLUSIONS

Pre-hospital MTP activation is useful to identify patients that require an urgent blood transfusion on arrival at the ED. Further analysis should be considered to evaluate the implementation of the Shock Index as a criterion to activate MTP.

Screening of lncRNA-miRNA-mRNA Coexpression Regulatory Networks Involved in Acute Traumatic Coagulation Dysfunction Based on CTD, GeneCards, and PharmGKB Databases

Competitive endogenous RNA (ceRNA) networks play crucial roles in multiple biological processes and development of diseases. They might serve as diagnostic and prognosis markers as well as therapeutic targets. The purpose of this study was to identify a novel ceRNA network involving KCNQ1OT1, hsa-miR-24-3p, and VWF in acute traumatic coagulopathy (ATC) based on databases search. We searched the CTD, GeneCards, and PharmGKB databases for ATC-related target genes using Coagulopathy as a keyword. Upstream miRNAs and lncRNAs of the candidate target VWF were then explored using the miRWalk, microT, TargetScan, RNA22 and Tarbase, and DIANA-LncBase and Starbase databases, respectively. A KCNQ1OT1-hsa-miR-24-3p-VWF ceRNA network was constructed by R “ggalluvial” package. Interaction between KCNQ1OT1, hsa-miR-24-3p, and VWF was examined, and their expression was quantified in the peripheral blood samples from 30 ATC patients and liver tissues of ATC rat models. Forty-one ATC-related target genes were identified following data retrieval from publicly available databases, of which VWF was selected as the target and used for the subsequent analysis. KCNQ1OT1 and hsa-miR-24-3p were confirmed to be the key upstream regulatory factors of VWF. KCNQ1OT1-hsa-miR-24-3p-VWF coexpression regulatory network was constructed where KCNQ1OT1 competitively bound to hsa-miR-24-3p and attenuated its binding to VWF. Both the liver tissues of ATC rats and peripheral blood samples from ATC patients showed increased hsa-miR-24-3p expression and decreased VWF and KCNQ1OT1 expression. Collectively, we described the KCNQ1OT1-hsa-miR-24-3p-VWF ceRNA network in the development of ATC. We propose a new ceRNA that could help in the diagnosis and treatment of ATC.

Adipose tissue: a neglected organ in the response to severe trauma?

Despite the manifold recent efforts to improve patient outcomes, trauma still is a clinical and socioeconomical issue of major relevance especially in younger people. The systemic immune reaction after severe injury is characterized by a strong pro- and anti-inflammatory response. Besides its functions as energy storage depot and organ-protective cushion, adipose tissue regulates vital processes via its secretion products. However, there is little awareness of the important role of adipose tissue in regulating the posttraumatic inflammatory response. In this review, we delineate the local and systemic role of adipose tissue in trauma and outline different aspects of adipose tissue as an immunologically active modifier of inflammation and as an immune target of injured remote organs after severe trauma.

Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers

Introduction: Uncontrolled bleeding is a preventable cause of death in rural trauma. Herein, we examined the appropriateness, effectiveness, and safety of tourniquet application for bleeding control in a rural trauma system.Methods: Medical records of adult patients admitted to our academic Level I trauma center between July 2015 and December 2018 were retrospectively reviewed. Demographics (age, gender), injury (Injury severity score, Glascow Coma scale, mechanism of injury), tourniquet (type, tourniquet application site, tourniquet duration, place of application and removal, indication), and outcome data (complications such as amputation, acute kidney injury, rhabdomyolysis, or nerve palsy and mortality) were collected. Tourniquet indications, effectiveness, and complications were evaluated. Data were compared to those in urban settings.Results: Ninety-two patients (94 tourniquets) were identified, of which 58.7% incurred penetrating injuries. Eighty-seven tourniquets (92.5%) were applied in the prehospital setting. Twenty tourniquets (21.3%) were applied to patients without an appropriate indication. Two of these tourniquets were applied in a hospital setting, while 18 occurred in the prehospital setting (p = 0.638). Patients with a non-indicated tourniquet presented with a higher hemoglobin level on admission, received less packed red blood cell units within the first 24 hours of hospitalization, and were less likely to require surgery for hemostasis. None of the non-indicated tourniquets led to a complication. Indicated tourniquets were deemed ineffective in seven cases (9.5%); they were all applied in the prehospital setting. The average tourniquet time was 123 min in rural vs. 48 min in urban settings, p < 0.001. There was no significant difference in mortality, amputation rates and incidence of nerve palsy between the rural and urban settings.Conclusion: Even with long transport times, early tourniquet application for hemorrhage control in rural settings is safe with no significant attributable morbidity and mortality compared to published studies on urban civilian tourniquet use. The observed rates of non-indicated and ineffective tourniquets indicate suboptimal tourniquet usage and application. Opportunity exists for standardized hemorrhage control training on the use of direct pressure and pressure dressings, indications for tourniquet use, and effective tourniquet application.

Trauma-induced pulmonary thromboembolism: What's update?

Trauma-induced pulmonary thromboembolism is the second leading cause of death in severe trauma patients. Primary fibrinolytic hyperactivity combined with hemorrhage and consequential hypercoagulability in severe trauma patients create a huge challenge for clinicians. It is crucial to ensure a safe anticoagulant therapy for trauma patients, but a series of clinical issues need to be answered first, for example, what are the risk factors for traumatic venous thromboembolism? How to assess and determine the status of coagulation dysfunction of patients? When is the optimal timing to initiate pharmacologic prophylaxis for venous thromboembolism? What types of prophylactic agents should be used? How to manage the anticoagulation-related hemorrhage and to determine the optimal timing of restarting chemoprophylaxis? The present review attempts to answer the above questions.

Physiological Changes in Subjects Exposed to Accidental Hypothermia: An Update

Background

Accidental hypothermia (AH) is an unintended decrease in body core temperature (BCT) to below 35°C. We present an update on physiological/pathophysiological changes associated with AH and rewarming from hypothermic cardiac arrest (HCA).

Temperature Regulation and Metabolism

Triggered by falling skin temperature, Thyrotropin-Releasing Hormone (TRH) from hypothalamus induces release of Thyroid-Stimulating Hormone (TSH) and Prolactin from pituitary gland anterior lobe that stimulate thyroid generation of triiodothyronine and thyroxine (T4). The latter act together with noradrenaline to induce heat production by binding to adrenergic β3-receptors in fat cells. Exposed to cold, noradrenaline prompts degradation of triglycerides from brown adipose tissue (BAT) into free fatty acids that uncouple metabolism to heat production, rather than generating adenosine triphosphate. If BAT is lacking, AH occurs more readily.

Cardiac Output

Assuming a 7% drop in metabolism per °C, a BCT decrease of 10°C can reduce metabolism by 70% paralleled by a corresponding decline in CO. Consequently, it is possible to maintain adequate oxygen delivery provided correctly performed cardiopulmonary resuscitation (CPR), which might result in approximately 30% of CO generated at normal BCT.

Liver and Coagulation

AH promotes coagulation disturbances following trauma and acidosis by reducing coagulation and platelet functions. Mean prothrombin and partial thromboplastin times might increase by 40-60% in moderate hypothermia. Rewarming might release tissue factor from damaged tissues, that triggers disseminated intravascular coagulation. Hypothermia might inhibit platelet aggregation and coagulation.

Kidneys

Renal blood flow decreases due to vasoconstriction of afferent arterioles, electrolyte and fluid disturbances and increasing blood viscosity. Severely deranged renal function occurs particularly in the presence of rhabdomyolysis induced by severe AH combined with trauma.

Conclusion

Metabolism drops 7% per °C fall in BCT, reducing CO correspondingly. Therefore, it is possible to maintain adequate oxygen delivery after 10°C drop in BCT provided correctly performed CPR. Hypothermia may facilitate rhabdomyolysis in traumatized patients. Victims suspected of HCA should be rewarmed before being pronounced dead. Rewarming avalanche victims of HCA with serum potassium > 12 mmol/L and a burial time >30 min with no air pocket, most probably be futile.

Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.

Personalized modulation of coagulation factors using a thrombin dynamics model to treat trauma-induced coagulopathy

Current trauma-induced coagulopathy resuscitation protocols use slow laboratory measurements, rules-of-thumb, and clinician gestalt to administer large volumes of uncharacterized, non-tailored blood products. These one-size-fits-all treatment approaches have high mortality. Here, we provide significant evidence that trauma patient survival 24 h after hospital admission occurs if and only if blood protein coagulation factor concentrations equilibrate at a normal value, either from inadvertent plasma-based modulation or from innate compensation. This result motivates quantitatively guiding trauma patient coagulation factor levels while accounting for protein interactions. Toward such treatment, we develop a Goal-oriented Coagulation Management (GCM) algorithm, a personalized and automated ordered sequence of operations to compute and specify coagulation factor concentrations that rectify clotting. This novel GCM algorithm also integrates new control-oriented advancements that we make in this work: an improvement of a prior thrombin dynamics model that captures the coagulation process to control, a use of rapidly-measurable concentrations to help predict patient state, and an accounting of patient-specific effects and limitations when adding coagulation factors to remedy coagulopathy. Validation of the GCM algorithm's guidance shows superior performance over clinical practice in attaining normal coagulation factor concentrations and normal clotting profiles simultaneously.

Liposome-encapsulated hemoglobin (HbV) transfusion rescues rats undergoing progressive lethal 85% hemorrhage as a result of an anti-arrhythmogenic effect on the myocardium

Liposome-encapsulated hemoglobin vesicles (HbV) can serve as a blood substitute with oxygen-carrying capacity comparable to that of human blood and lethal hemorrhage is associated with lethal arrhythmias. To investigate the resuscitation effect of HbV on lethal hemorrhage and anti-arrhythmogenesis, we performed optical mapping analysis (OMP) and electrophysiological study (EPS) in graded blood exchange (85% blood loss) in the rat model. We also measured cardiac autonomic activity, as assessed by heart rate variability (HRV), and changes in plasma norepinephrine and left ventricle ejection fraction (LVEF) by echocardiography. Pathological study on Connexin43 was performed. A 5% albumin (ALB group), washed rat erythrocytes (wRBC group), and HbV (HbV group) were used as a resuscitation fluid. The survival effects over 24 hours were examined. All rats died in the ALB group, whereas almost all survived for 24-hours period in wRBC and HbV groups. OMP showed impaired action potential duration dispersion (APDd) in the ALB group, whereas normal APDs in HbV and wRBC groups. Lethal arrhythmias were induced by EPS in the ALB group, but not in wRBC and HbV groups. HRV indices, LVEF, Connexin43 were preserved in HbV and wRBC groups. Lethal hemorrhage causes lethal arrhythmias in the presence of impaired APDd. HbV acutely rescues lethal hemorrhage by preventing lethal arrhythmias and preserving arrhythmogenic factors.

Hyperendogenous Heparinization Suggests a Guideline for the Management of Massive Wasp Stings in Two Victims

Bees and wasps (order Hymenoptera) are commonly encountered worldwide and often deliver defensive stings when in contact with humans. Massive envenomation resulting from >50 stings causes a toxic reaction and life-threatening complications that typically result in rhabdomyolysis and disseminated intravascular coagulation. Two male patients who were stung over 80 times by wasps experienced severe coagulation abnormality. Consecutive examination by thromboelastography (TEG) guided by heparinase treatment during their hospitalization evidenced heparin-like coagulation dysfunction despite no clinical use of heparin-like substances. Numerous tests were also conducted to confirm whether the coagulation abnormalities could be attributed to hyperendogenous heparinization and allergic reaction, rhabdomyolysis, and vascular endothelial cell injury without apparent disseminated intravascular coagulation, which might all be affected by the production of endogenous heparin. The reduced coagulation potential caused by hyperendogenous heparinization was associated with the binding of antithrombin and the activation of fibrinolysis. In addition, TEG-identified coagulopathy was moderated using protamine for heparin neutralization. The massively envenomed patients survived and were discharged after completion of medical care. We also review clinical manifestations from other published case reports, including topical treatment. Our study provides clinical evidence and guidance for diagnosis via TEG and appropriate intervention with protamine for patients with massive wasp envenomation.

The association of ABO blood groups and trauma outcomes: A retrospective analysis of 3779 patients

Background:

There is currently a lack of understanding regarding the link between ABO blood types with outcomes of traumatically injured patients. The purpose of this study was to determine the association of ABO blood types with outcomes in traumatically injured patients separated by injury type.

Methods:

This retrospective study evaluated trauma patients at an urban, Level 1 trauma center from January 1, 2017, through December 31, 2017. Patients were excluded if they were pregnant or <16 years old. Recorded outcomes included: ABO blood group, mortality, Injury Severity Score (ISS), race, injury type, mechanism of injury, and complications. Data analysis was performed using descriptive statistics including Chi-squared, Kruskal–Wallis, and F-test calculations.

Results:

A total of 3779 patients were included in this study. No significant differences were present in mean age or ISS between blood types. In patients with penetrating injuries, blood type O was associated with a significant increase in mortality (P = 0.017), red blood cell transfusion (P = 0.027), and massive transfusion protocol (MTP) (P = 0.026) compared to non-O blood types. In patients with blunt injuries, blood type AB was associated with a significant increase in mortality rate compared to non-AB blood types (P = 0.03).

Conclusion:

ABO blood type is connected with an underlying process which affects trauma outcomes, including mortality. Blood type O is associated with increased blood transfusion, MTP, and mortality during the initial hospitalization following a traumatic penetrating injury, while blood type AB is associated with increased mortality during the initial hospitalization following a blunt traumatic injury.

The Role of DAMPS in Burns and Hemorrhagic Shock Immune Response: Pathophysiology and Clinical Issues. Review

Severe or major burns induce a pathophysiological, immune, and inflammatory response that can persist for a long time and affect morbidity and mortality. Severe burns are followed by a "hypermetabolic response", an inflammatory process that can be extensive and become uncontrolled, leading to a generalized catabolic state and delayed healing. Catabolism causes the upregulation of inflammatory cells and innate immune markers in various organs, which may lead to multiorgan failure and death. Burns activate immune cells and cytokine production regulated by damage-associated molecular patterns (DAMPs). Trauma has similar injury-related immune responses, whereby DAMPs are massively released in musculoskeletal injuries and elicit widespread systemic inflammation. Hemorrhagic shock is the main cause of death in trauma. It is hypovolemic, and the consequence of volume loss and the speed of blood loss manifest immediately after injury. In burns, the shock becomes evident within the first 24 h and is hypovolemic-distributive due to the severely compromised regulation of tissue perfusion and oxygen delivery caused by capillary leakage, whereby fluids shift from the intravascular to the interstitial space. In this review, we compare the pathophysiological responses to burns and trauma including their associated clinical patterns.

Temperature loss by ventilation in a calorimetric bench model

In intensive care medicine heat moisture exchangers are standard tools to warm and humidify ventilation gases in order to prevent temperature loss of patients or airway epithelia damage. Despite being at risk of hypothermia especially after trauma, intubated emergency medicine patients are often ventilated with dry and in winter probably cold ventilation gases. We tried to assess the amount of temperature-loss due to ventilation with cold, dry medical oxygen in comparison to ventilation with warm and humidified oxygen. We ventilated a 50-kg water-dummy representing the calorimetric capacity of a 60-kg patient over a period of 2 hours (tidal volume 6.6 mL/kg = 400 mL; respiratory rate 13/min). Our formal null-hypothesis was that there would be no differences in temperature loss in a 50 kg water-dummy between ventilation with dry oxygen at 10°C vs. ventilation with humidified oxygen at 43°C. After 2 hours the temperature in the water-dummy using cold and dry oxygen was 29.7 ± 0.1°C compared to 30.4 ± 0.1°C using warm and humidified oxygen. This difference in cooling rates between both ventilation attempts of 0.7 ± 0.1°C after 2 hours represents an increased cooling rate of ~0.35°C per hour. Ventilation with cool, dry oxygen using an automated transport ventilator resulted in a 0.35°C faster cooling rate per hour than ventilation with warm humidified oxygen in a bench model simulating calorimetric features of a 60-kg human body.

Combined Administration of Fibrinogen and Factor XIII Concentrate Does Not Improve Dilutional Coagulopathy Superiorly Than Sole Fibrinogen Therapy: Results of an In-Vitro Thrombelastographic Study

The early administration of fibrinogen has gained wide acceptance for the treatment of major hemorrhage, whereas the substitution of coagulation factor XIII (FXIII) is only supported by a low level of evidence. This study aimed to answer the question of whether a combined therapy of fibrinogen/FXIII substitution performs superiorly to sole fibrinogen administration in the treatment of dilutional coagulopathy. An in-vitro model of massive transfusion was used to compare the effect of combined fibrinogen/FXIII administration to that of sole fibrinogen therapy for the treatment of dilutional coagulopathy. For this purpose, the blood of red blood cell concentrates, fresh frozen plasma, and platelet concentrates were reconstituted in a ratio of 4:4:1, and then diluted with gelatin by 20% and 40%, respectively. Clot formation and stability were analyzed by thrombelastography. Both sole fibrinogen therapy (equivalent to 50 mg/kg) and the combined administration of fibrinogen (equivalent to 50 mg/kg) and FXIII (equivalent to 75 International Units (IU)/kg) increased fibrinogen-dependent mean clot firmness independently of the degree of dilution (20% dilution: 7 (6.3–7.8) mm; 20% dilution fibrinogen: 13.5 (13–17.3) mm; 20% dilution fibrinogen/FXIII: 16.5 (15.3–18.8) mm; 40% dilution: 3 (2–3.8) mm; 40% dilution fibrinogen: 8 (7–11.3) mm; 40% dilution fibrinogen/FXIII: 10 (8.3–11.8) mm; all p < 0.01). However, no differences were identified between the two treatment arms. Compared to fibrinogen therapy, no beneficial effect of the combined administration of fibrinogen and FXIII for the treatment of dilutional coagulopathy was detected in this in-vitro massive transfusion model. The result was independent of the degree of dilution.

Platelet-enhanced plasma: Characterization of a novel candidate resuscitation fluid's extracellular vesicle content, clotting parameters, and thrombin generation capacity

BACKGROUND

Platelet transfusion is challenging in emergency medicine because of short platelet shelf life and stringent storage conditions. Platelet-derived extracellular vesicles (PEV) exhibit platelet-like properties. A plasma generated from expired platelet units rich in procoagulant PEV may be able to combine the benefits of plasma and platelets for resuscitation while increasing shelf life and utilizing an otherwise wasted resource.

STUDY DESIGN AND METHODS

Freeze-thaw cycling of platelet-rich plasma (PRP) followed by centrifugation to remove platelet remnants was utilized to generate platelet-enhanced plasma (PEP). An in vitro model of dilutional coagulopathy was also designed and used to test PEP. Rotational thromboelastometry and calibrated automated thrombography were used to assess clotting and extracellular vesicles (EV) procoagulant activity. Capture arrays were used to specifically measure EV subpopulations of interest (ExoView™, NanoView Biosciences). Captured vesicles were quantified and labeled with Annexin-V-FITC, CD41-PE, and CD63-AF647. Platelet alpha granule content (platelet-derived growth factor AB, soluble P-selectin, vascular endothelial growth factor A, and neutrophil activating peptide 2-chemokine (C-X-C motif) ligand 7) was measured. Commercially available platelet lysates were also characterized.

RESULTS

PEP is highly procoagulant, rich in growth factors, exhibits enhanced thrombin generation, and restores hemostasis within an in vitro model of dilutional coagulopathy. The predominant vesicle population were PEV with 7.0 × 10⁹ CD41+PS+ EV/ml compared to 4.7 × 10⁷ CD41+PS+ EV/ml in platelet-free plasma (p = .0079). Commercial lysates show impaired but rescuable clotting.

DISCUSSION

PEP is a unique candidate resuscitation fluid containing high PEV concentration with preliminary evidence, indicating a potential for upscaling the approach using platelet concentrates. Commercial lysate manufacturer workflows may be suitable for this, but further optimization and characterization of PEP is required.

Fibrinolytic shutdown diagnosed with rotational thromboelastometry represents a moderate form of coagulopathy associated with transfusion requirement and mortality: A retrospective analysis

BACKGROUND

Viscoelastic techniques have made it possible to describe specific fibrinolytic phenotypes (physiological, hyperfibrinolysis and shutdown) and to establish a relationship of these phenotypes with outcome. However, there remains a debate as to whether shutdown is a state of hypercoagulability or rather a coagulopathy with moderate fibrinolysis and fibrinogen consumption.

OBJECTIVES

Our objectives were to describe the relationship between fibrinolytic phenotypes and outcomes, and to report the effects of tranexamic acid (TXA) administration.

DESIGN

This was a retrospective analysis of prospectively acquired data from a trauma registry.

SETTING

An academic level 1 trauma centre in the Lyon Region, from March 2011 to December 2016.

PATIENTS

We included all injured patients who had a rotational thromboelastometry analysis at admission. Fibrinolytic phenotypes were determined according to the maximum lysis: shutdown less than 3%, physiological 3 to 15%, hyperfibrinolysis more than 15%.

MAIN OUTCOME MEASURE

Mortality at 24 h and at hospital discharge.

RESULTS

During the study period, 473 patients were included with the following phenotypes: physiological (344 patients, 73%), shutdown (107 patients, 23%) and hyperfibrinolysis (22 patients, 5%). There was an increase in injury severity, prothrombin time ratio, fibrin degradation products and transfusion requirements from the physiological to the shutdown and hyperfibrinolysis phenotypes. Prehospital TXA administration increased the rate of shutdown and decreased the maximum lysis value at admission. After adjustment, multivariate analysis showed that fibrinolytic phenotypes, but not TXA, were independently associated with an increased risk of early death and death before hospital discharge: shutdown [odds ratio (95% confidence interval)] 2.4 (1.2 to 4.8) and hyperfibrinolysis 67.9 (7.4 to 624.2).

CONCLUSION

The results of the current study suggest that shutdown, which is associated with injury severity and mortality, probably reflects a moderate form of coagulopathy and fibrinolysis rather than a hypercoagulopathy. Therefore, the observation of shutdown fibrinolysis on thromboelastography/rotational thromboelastometry should not lead to withholding but rather to the administration of TXA.

Glycocalyx components affect platelet function, whole blood coagulation, and fibrinolysis: an in vitro study suggesting a link to trauma-induced coagulopathy

BACKGROUND

The mechanisms of trauma induced coagulopathy (TIC) are considered multifactorial. Amongst others, however, shedding of the endothelial glycocalyx resulting in increased concentrations of glycocalyx fragments in plasma might also play a role. Thus, we hypothesized that shedded glycocalyx components affect coagulation and may act as humoral mediators of TIC.

METHODS

To investigate effects of heparan sulfate, chondroitin sulfate, syndecan-1, versican, and thrombomodulin we added these fragments to in vitro assays of whole blood from healthy volunteers to yield concentrations observed in trauma patients. Platelet function, whole blood coagulation, and fibrinolysis were measured by standard coagulation tests, impedance aggregometry (IA), and viscoelastic tests (VET). To assess dose-response relationships, we performed IA with increasing concentrations of versican and VET with increasing concentrations of thrombomodulin.

RESULTS

Intrinsically activated clotting times (i.e., activated partial thromboplastin time and intrinsically activated VET with and without heparinase) were unaffected by any glycocalyx fragment. Thrombomodulin, however, significantly and dose-dependently diminished fibrinolysis as assessed by VET with exogenously added rt-PA, and increased rt-PA-induced lysis Indices after 30 (up to 108% of control, p <  0,0001), 45 (up to 368% of control, p <  0,0001), and 60 min (up to 950% of control, p <  0,0001) in VET. Versican impaired platelet aggregation in response to arachidonic acid (up to - 37,6%, p <  0,0001), ADP (up to - 14,5%, p <  0,0001), and collagen (up to - 31,8%, p <  0,0001) in a dose-dependent manner, but did not affect TRAP-6 induced platelet aggregation. Clotting time in extrinsically activated VET was shortened by heparan sulfate (- 7,2%, p = 0,024), chondroitin sulfate (- 11,6%, p = 0,016), versican (- 13%, p = 0,012%), and when combined (- 7,2%, p = 0,007).

CONCLUSIONS

Glycocalyx components exert distinct inhibitory effects on platelet function, coagulation, and fibrinolysis. These data do not support a 'heparin-like auto-anticoagulation' by shed glycosaminoglycans but suggest a possible role of versican in trauma-induced thrombocytopathy and of thrombomodulin in trauma-associated impairment of endogenous fibrinolysis.

Evolving concepts and strategies in the management of polytrauma patients

Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.

Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure

BACKGROUND

Musculoskeletal injuries are common following trauma and variables that are associated with late femur fracture fixation are important to perioperative management. Furthermore, the association of late fracture fixation and multiple organ failure (MOF) is not well defined.

METHODS

We performed a retrospective cohort investigation from 2 academic trauma centers.

INCLUSION CRITERIA

age 18-89 years, injury severity score (ISS) >15, femoral shaft fracture requiring operative fixation, and admission to the intensive care unit >2 days. Admission physiology variables and abbreviated injury scale (AIS) scores were obtained. Lactate was collected as a marker of shock and was described as admission lactate (LacAdm) and as 24-hour time-weighted lactate (LacTW24h), which reflects an area under the curve and is considered a marker for the overall depth of shock. The primary aim was to evaluate clinical variables associated with late femur fracture fixation (defined as ≥24 hours after admission). A multivariable logistic regression model tested variables associated with late fixation and is reported by odds ratio (OR) with 95% confidence interval (CI). The secondary aim evaluated the association between late fixation and MOF, defined by the Denver MOF score. The summation of scores (on a scale from 0 to 3) from the cardiac, pulmonary, hepatic, and renal systems was calculated and MOF was confirmed if the total daily sum of the worst scores from each organ system was >3. We assessed the association between late fixation and MOF using a Cox proportional hazards model adjusted for confounding variables by inverse probability weighting (a propensity score method). A P value <.05 was considered statistically significant.

RESULTS

One hundred sixty of 279 (57.3%) patients received early fixation and 119 of 279 (42.7%) received late fixation. LacTW24h (OR = 1.66 per 1 mmol/L increase, 95% CI, 1.24-2.21; P < .001) and ISS (OR = 1.07 per 1-point increase, 95% CI, 1.03-1.10; P < .001) were associated with higher odds of late fixation. Late fixation was associated with a 3-fold increase in the odds of MOF (hazard ratio [HR] = 3.21, 95% CI, 1.48-7.00; P < .01).

CONCLUSIONS

In a cohort of multisystem trauma patients with femur fractures, greater injury severity and depth of shock, as measured by LacTW24h, were associated with late operative fixation. Late fixation was also associated with MOF. Strategies to reduce the burden of MOF in this population require further investigation.